Dural Puncture-Induced Intracranial Hypotension Causing Diplopia

Case Report: Unilateral Cranial Nerve VI Palsy Secondary to Intracranial Hypotension

SIGNIFICANCE

Intracranial hypotension is a condition that occurs from a cerebrospinal fluid leak. Various visual symptoms have been associated with this condition. Cranial nerve VI (CN VI) palsies are the most common ocular manifestation, as the abducens nerve is prone to injury because of its intracranial anatomical course.

PURPOSE

This case report presents a CN VI palsy secondary to intracranial hypotension from ventriculoperitoneal shunt overfiltration. Diagnosis, treatment, and management considerations are discussed. No identifiable health information was included in this case report.

CASE REPORT

A 70-year-old White man was referred to the eye clinic for evaluation of binocular horizontal diplopia. The patient had a recent history of a left ventriculoperitoneal shunt for a persistent cerebrospinal fluid leak after complex mastoid surgery. The patient was also symptomatic for positional headaches, which improved in a recumbent position. He was diagnosed with a left CN VI palsy secondary to intracranial hypotension from a ventriculoperitoneal shunt overfiltration. The patient was followed up by neurosurgery for shunt adjustments to resolve the overfiltration. Binocular horizontal diplopia was managed conservatively with Fresnel prism.

CONCLUSIONS

Intracranial hypotension should be considered in patients presenting with cranial nerve palsies and positional headaches. Obtaining neuroimaging and comanaging with neurology or neurosurgery are advised to make prompt diagnosis and treatment. Careful clinical monitoring and conservative diplopia therapy are recommended as visual symptoms improve upon resolution of the cerebrospinal fluid leak.

Unilateral Abducens Palsy and Headache in Postpartum Patient Presenting to Ophthalmology

Postpartum patients rarely present to eye casualty. Here we report a case of a seven-day postpartum patient with sudden onset horizontal diplopia and an occipital headache from the perspective of the ophthalmology eye casualty in a tertiary hospital. Intracranial imaging ruled out any acute pathology. The patient required epidural anaesthesia during labour, and a diagnosis of a post-dural puncture headache (PDPH) with an abducens nerve palsy was reached. A blood patch was not provided in this case. The headache settled and the diplopia self-resolved three weeks postpartum. PDPH with extra-ocular muscle paresis is rare, and, as the diplopia onset usually follows the characteristic orthostatic headaches of PDPH, it is likely that these patients are followed up by obstetricians or anaesthetists. These patients rarely present to ophthalmology services to receive this diagnosis, therefore ophthalmologists might not be familiar with this pathology. To our knowledge, this is the first case report of PDPH with cranial nerve palsy that has been documented to present to an ophthalmology department.

Intracranial hypotension as a complication of lumbar puncture prior to elective aneurysm clipping

Background:

Lumbar dural defects are an uncommon but important cause of persistent intracranial hypotension in the neurosurgical population. We present a case of intracranial hypotension after elective craniotomy due to a lumbar puncture performed 3 weeks earlier.

Case Description:

A 55-year-old female underwent uneventful craniotomy for clipping of an unruptured left middle cerebral artery bifurcation aneurysm. Postoperatively, the patient showed a gaze deviation and failed to wake up. Computed tomography demonstrated significant postoperative pneumocephalus. Family members indicated that the patient underwent a lumbar puncture 3 weeks prior to surgery to rule out a subarachnoid hemorrhage. The excessive pneumocephalus was initially interpreted as a result of spinal cerebrospinal fluid leak, and the patient was placed in the Trendelenburg position. This positioning resulted in some improvement in her mental status, although she was unable to tolerate any subsequent elevation in the head of her bed. Magnetic resonance imaging analysis of her spinal axis did not demonstrate any evidence of cerebrospinal fluid leak, but a subsequent lumbar blood patch resulted in rapid and dramatic improvement in the patient's status. She was subsequently discharged after an uneventful hospital stay.

Conclusion:

Although uncommon, persistent intracranial hypotension caused by lumbar dural defects must be considered in patients who have recently undergone procedures that compromise the lumbar dura because prompt intervention can significantly improve the patient's condition.